## Summary

#### Objectives

To evaluate the quantity and quality of published vascular surgery research articles from the Gulf Cooperation Council (GCC) countries so as to identify areas for improvement.

#### Design

Descriptive study.

#### Materials

Published MEDLINE articles on vascular surgery from the GCC countries (1960–2010).

#### Methods

Critical analysis of the articles.

#### Results

A total of 146 articles were studied, majority of which were case series/case reports (55.5%); 33% of the articles were prospective. The first author was from a university in 67.1% of the articles. Only one randomized controlled trial was found. The median (range) impact factor of the journals was 1.16 (0.16–12.64). Kuwait had the highest number of publications/country, standardized/100,000 inhabitants. There were 11 experimental studies, which were all from Kuwait. More statistically significant, experimental vascular surgery papers were published prior to 1993 (11/30 compared with 0/111 afterward, p < 0.0001; Fisher exact test). The GCC countries had the lowest vascular surgery research output compared with Turkey, Hong Kong, Singapore, and Japan when standardized by the population. The h index of the GCC countries' vascular research publications was the lowest (19) compared with the other four countries (29–97). Furthermore, the average citation of the GCC countries (5.81) was similar to Turkey (5.66), but less than Hong Kong (17.38), Singapore (12.79), and Japan (11.75).

#### Conclusion

The quality and quantity of vascular surgery research in the GCC countries should be improved to answer important local questions related to vascular diseases. This needs better strategic planning and more collaboration between various institutions.

## Keywords

developing countries;priority;research design;vascular research

## 1. Introduction

Most Gulf Cooperation Council (GCC) countries have a strong developing economy and a high gross domestic product.1 This was associated with improvements in the standards of health care. The GCC countries are United Arab Emirates (UAE), Saudi Arabia, Kuwait, Qatar, Bahrain, and Oman. The total population of the GCC countries has increased from 7.8 million in 1970 to 39.2 million in 2010.2 With continued growth in the population, and improved health care, the percentage of the aging population is on the rise. Therefore, the GCC countries will experience an increasing burden of cardiovascular disease similar to Western countries.

In addition, the Intervention Diabetic Federation placed the GCC countries among the top 10 countries in the world having a high prevalence of diabetes. Moreover, the prevalence of obesity in the GCC countries is more than 60%.3 The prevalence of renal failure and hypertension is also increasing. Therefore, health care providers and planners should anticipate an increase in the burden of vascular diseases in the GCC countries in the coming decades.

Local data on these diseases are important for having a successful strategic plan for management and prevention. We cannot achieve that without knowing which areas have been studied and what the quality of the vascular surgery research performed is. This will enable us to identify areas of deficiency that needed to be acted on. Furthermore, methods of improving the quality of vascular research have to be identified. We aimed in this study to analyze the areas of vascular surgery research conducted in the GCC countries and their quality as well as to identify research areas that need to be augmented.

## 2. Methods

A MEDLINE search of the PubMed website on vascular surgery publications from the GCC countries covering the period between 1960 and 2010 was performed in June 2011.4 General terms used for the search were “vascular”, “vessel” and “surgery”, and specific GCC country names were entered. Of the 491 citations, a total of 363 relevant abstracts were retrieved, and all were reviewed manually. Papers related to cardiac surgery were excluded. A total of 154 articles were related to vascular surgery. Papers were obtained through the National Medical Library of the Faculty of Medicine and Health Sciences, UAE University. Eleven of these could not be retrieved and were studied from the abstracts.

The articles were critically analyzed and classified according to a prepared protocol developed specifically for the study. This protocol included journal of publication, country name, MEDLINE category, first authors' affiliation, year of publication, journal impact factor in 2010,5 study design of publication, methods of data collection, area of study, area of vascular surgery, and reason(s) for exclusion of an article.

The contents of the articles were studied. Data were reviewed and analyzed by the first author (A.J.). Controversial and unclear issues were discussed between the authors and a consensus was reached to fill the form. Eight articles were excluded (Appendix 1)—seven papers had data from other countries and one paper was judged to be a Salami publication. Therefore, a total of 146 papers were analyzed. Data were coded and entered into a database.

### 2.1. Comparison with other Asian countries

The SCI (Web of Knowledge, all databases) was used to search for the average citation and h index of vascular surgery articles of the GCC countries in July 2013. 6 The h index is defined as the number of items, h, which have at least h citations. 7 The search included the GCC country name in different forms [e.g., UAE, Saudi Arabia (KSA)] in the affiliation section. The period was defined by the date of publication. Data of individual countries were retrieved from the citation report of the search.

The search output of all GCC countries combined together was compared with another four Asian countries, which are known to be active in medical research. These included Turkey, Singapore, Hong Kong, and Japan.

### 2.2. Statistical analysis

The number of publications of a specific country was standardized by the country population of 2007.1 ;  8 Nonparametric Fishers exact test was used to compare categorical data of two independent groups because of the small number of the cells in the two-by-two tables.9 A p value < 0.05 was considered significant. The following standard formula was used to calculate the 95% confidence interval (95% CI) of percentages:

 ${\displaystyle 95\%\quad {\mbox{CI}}=p\pm 1.96\times {\mbox{square}}\quad {\mbox{root}}\quad {\mbox{of}}\left({\mbox{pq}}/n\right)}$

where p is the studied percentage, q is the alternate percentage, and n is the sample size (n = 146). 10 Data were analyzed with PASW Statistics 19 (SPSS Inc., Chicago, IL, USA).

## 3. Results

A total of 58.2% of the articles were published during the past 10 years (Fig. 1). Kuwait had the highest number of published articles/100,000 populations followed by Qatar and Saudi Arabia (Table 1). The median (range) impact factor of these articles was 1.16 (range: 0.16–12.64) in those journals having citation reports. Majority were case series or case reports (55.5%) followed by case–control studies (9.6%) and cohort studies (9.6%). Only one randomized controlled trial was found (Table 2). Data collection was prospective in only 48 articles (32.9%). The majority was categorized by MEDLINE as original articles (69.9%), followed by case reports (21.9%; Table 3). The first author was affiliated to a university in 98 articles (67.1%), to a community hospital in 38 articles (26%), and to a military hospital in 10 articles (6.8%).

 Figure 1. MEDLINE-studied vascular surgery research publications stemming from the Gulf Cooperation Council countries (n = 146) published during the period between 1960 and 2010.

Table 1. Number of studied vascular surgery publications/country, standardized/100,000 population.
Country No. of papers Population Standardized/100,000
Kuwait 38 2,851,144 1.33
Qatar 8 840,635 0.95
Saudi Arabia 86 24,734,533 0.35
UAE 8 4,380,439 0.18
Oman 6 4,595,133 0.13
Total 146 37,401,884 0.39

UAE = United Arab Emirates.

Table 2. Study design of vascular surgery publications.
Study design No.  % Lower limit CI Upper limit CI
Case series/case reports 81 55.5 47.44 63.56
Case–control study 14 9.6 4.82 14.38
Cohort study 14 9.6 4.82 14.38
Review 10 6.8 2.72 10.88
Non-RCT 8 5.5 1.8 9.2
Uncontrolled trial 8 5.5 1.8 9.2
Cross-sectional studies 6 4.1 0.88 7.32
Letter/editorial 2 1.4 −0.51 3.31
RCT 1 0.7 −0.65 2.05
Unknown 2 1.4 −0.51 3.31
Total 146 100

CI = 95% confidence interval; RCT = randomized controlled trial.

Table 3. MEDLINE category of vascular surgery publications.
Category No.  % Lower limit CI Upper limit CI
Original article 102 69.9 62.46 77.34
Case reports 32 21.9 15.19 28.61
Review articles 10 6.8 2.72 10.88
Others 2 1.4 −0.51 3.31
Total 146 100

CI = 95% confidence interval.

Table 4 shows the different areas of vascular research. Basic science was the leading area (18.5%), followed by diseases of the aorta (17.8%), vascular trauma (12.3%), and renal vascular access (12.3%). Table 5 shows the type of publication. The majority were treatment papers (54.1%). There were 11 (7.5%) experimental studies, which were all from Kuwait and were published prior to 1993. Epidemiological studies comprised only 5.5% of the papers.

Table 4. Area of study of vascular surgery publications.
Area of study No.  % Lower limit CI Upper limit CI
Basic vascular science 27 18.5 12.2 24.8
Aorta and major vessels 26 17.8 11.6 24.0
Vascular trauma 18 12.3 6.97 17.63
Renal vascular access 18 12.3 6.97 17.63
Venous 17 11.6 6.41 16.79
Peripheral arteries 15 10.3 5.37 15.23
A–V malformation 7 4.8 1.33 8.27
Cerebrovascular 4 2.7 0.07 5.33
Endovascular 4 2.7 0.07 5.33
Diabetic ulcer 4 2.7 0.07 5.33
Lymphatic 2 1.4 −0.51 3.31
Others 4 2.7 0.07 5.33
Total 146 100

A–V = arteriovenous; CI = 95% confidence interval.

Table 5. Type of study of vascular surgery publications.
Type of study No.  % Lower limit CI Upper limit CI
Intervention/treatment 79 54.1 46.02 62.18
Knowledge, attitude, and practice 26 17.8 11.6 24.0
Diagnostic 21 14.4 8.7 20.1
Experimental 11 7.5 3.23 11.77
Epidemiology 8 5.5 1.8 9.2
Others 1 0.7 −0.65 2.05
Total 146 100

CI = 95% confidence interval.

Fig. 2 shows the average citation and h index of the vascular surgery research articles of the GCC countries over time. There is a continuous increase of the h index over time whereas the average citation of the articles had dropped during the period between 2006 and 2010.

 Figure 2. The h index (black circles) and the average citation (white circles) of the vascular surgery research articles of the GCC countries during the period between 1960 and 2010. GCC = Gulf Cooperation Council.

Table 6 compares the vascular research quantity and quality of the GCC countries with other countries (Turkey, Singapore, Hong Kong, and Japan). The GCC countries had the lowest vascular surgery research output compared with the other four countries when standardized by the population (1.31 articles/100,000 population). The percentage of vascular surgery research of the GCC countries out of all the research output (1.4%) was similar to Hong Kong and Singapore (1.5% each), but less than Turkey (3.4%) and Japan (2.2%). The h index of the GCC countries' vascular research publications was the lowest (19) compared with the other four countries (29–97). Furthermore, the average citation of the GCC countries (5.81) was similar to Turkey (5.66), but less than Hong Kong (17.38), Singapore (12.79), and Japan (11.75).

Table 6. Quantity and quality of vascular surgery publications of the GCC countries compared with Turkey, Hong Kong, Singapore, and Japan as shown in PubMed and SCI for the period between 1960 and 2010.
Country PubMed articles PubMed vascular surgery articles  % of vascular surgery articles Population (2007) Vascular articles standardized for 100,000 population SCI vascular surgery articles  % of SCI articles out of PubMed articles Average citation h index
GCC countries 34,243 491 1.4 37,401,884 1.31 275 56 5.81 19
Turkey 91,785 3112 3.4 74,876,695 4.2 2433 78.2 5.66 34
Hong Kong 38,992 587 1.5 6,963,100 8.5 325 55.4 17.38 37
Singapore 30,036 456 1.5 4,436,281 10.4 237 52 12.79 29
Japan 715,966 15,576 2.2 127,966,709 12.2 9089 58.4 11.75 97

GCC = Gulf Cooperation Council.

## 4. Discussion

Vascular disease is a major health problem in the GCC countries that needs to be solved. Medical research on vascular disease plays a central role in defining our road map to find solutions for this problem. Identification of types of vascular diseases and prioritization of the urgent solution require knowledge of the vascular research stemming from the GCC countries.

This study has shown that publications on vascular surgery in the GCC countries, although moderate, have increased exponentially with time. Almost 60% of the articles were published during the past 10 years. Kuwait was the most productive GCC country in vascular research after the publications were standardized by the number of population. This is not only peculiar for vascular research, but also for medical research in general. We have previously shown that Kuwait had the highest number of medical research publications in the GCC countries when standardized by the population size.11 This has dropped temporarily after 1990 due to the Second Gulf War but then increased gradually. The medical publications from the other GCC countries were not affected by this factor and continued to increase exponentially. The same trends were also seen in trauma research of the UAE12 and pediatric trauma research of the GCC countries.13

More than half of the vascular research publications from the GCC countries were descriptive in nature including case series and case reports. These have a simple design and are nonexpensive to perform because there is no intervention or follow-up.14 About 10% were cohort studies with follow-up outcome, and another 10% had a case–control design. We should not underestimate the value of case series and case reports. Reporting case series with a small number of patients raised important concerns regarding serious conditions such as the relationship between the Kaposis sarcoma and acquired immunodeficiency syndrome, and the newborn optic neuritis caused by high concentrations of oxygen.15 It is encouraging to notice that about one-third of the articles were prospective in nature. Nevertheless, out of these, there was only one randomized controlled trial, which is the most solid research design capable of answering a specific research question.

It is of interest to find that all experimental vascular surgery papers stemmed from Kuwait prior to 1993. This highlights the importance of the impact of the research partnership model in developing countries. This model depends on mutual trust, national ownership, and development of national research capacity.16 Professor Bo Eklof, a well-known figure in venous surgery moved to Kuwait in September 1981,17 and left Kuwait after the Second Gulf War in 1990. He established a state-of-the-art surgical vascular unit, which was led by Swedish vascular surgeons in the early 1980s.17 The Swedish team carried with them, from Sweden, high experimental research skills that were patiently taught for young residents at early stages. These impressive historical experimental vascular surgery papers testify for the genuine impact on vascular surgery research in Kuwait. Furthermore, it is important to stress that building local capacity in developing countries by training surgeons on research methodology has a more lasting positive effect on the community than counting the number of papers published.18

Epidemiological studies constituted only 5.5% of the publications. Prevention using a public health approach is the most cost-effective method to reduce the toll of vascular diseases. The GCC countries are rapidly developing because of high revenues from oil exports. The desire to diversify the economy has led to many fast-paced construction sites, together with supporting infrastructure, and employing many young foreign workers. The population structure of the GCC countries is unique. It is a multinational young population with a male predominance.19 Trauma is a major cause of death and disability in this young population. Establishing a Trauma Registry in the UAE20 was very successful in promoting vascular trauma research.21 ;  22 This Trauma Registry was highly successful in the UAE demonstrating the value of legislative changes for injury prevention.23 ;  24 A similar approach can be adopted to tackle the problem of vascular diseases. Developing a Cardiovascular Disease Registry on a national and regional level will be essential to understand the extent and nature of vascular diseases. In fact, the major recommendation of the 5th Gulf Vascular Society Conference was to establish and continuously update a database of cardiovascular diseases in the GCC countries, to determine the size of the problem and to put appropriate plans to overcome the dangers arising from these diseases in the region.25

Most of the medical publications on vascular surgery in our region stemmed from universities. Academic researchers, who are knowledgeable in research methodology, should carry on their shoulders the responsibility of training junior staff and leading the research endeavors in their community. To achieve that goal, they should collaborate with nonacademic institutions and be supportive for the research activities of community and rural hospitals. King Saud University in Riyadh has established the first Vascular and Endovascular Surgery Fellowship Program, and the first group of students graduated in 2004. Candidates passing the final board examination are awarded a Specialty Certificate, “King Saud Fellowship in Vascular Surgery.”26 Moreover, a Peripheral Vascular Disease Research Chair with various ongoing research projects was established. This was led by Professor Louis Ignarro, the 1998 Nobel Prize winner in Medicine/Physiology.27 Furthermore, the recent establishment of the Gulf and Saudi Vascular Surgery Society will enrich vascular research endeavors in the region.25

Research gaps were identified in our analysis. Few research publications were found regarding endovascular management, diabetic foot management, and cerebrovascular diseases. These important areas of shortage need to be addressed in the future. Therefore, it is important to direct vascular research initiatives to fill the research gaps in this field in the GCC states. There is a desperate need to conduct community-screening projects, prevention programs, and patients education programs to cover vascular diseases in this part of the world.

Our study has shown that both the quantity and quality of vascular surgery research are less than other Asian countries including Singapore, Hong Kong, and Japan. The impact factor of the vascular surgery research (average citation) was similar to Turkey despite the fact that the percentage of vascular surgery research was less. It is clear that there is a need to increase both quantity and quality of vascular surgery research from the GCC countries.

Performing clinical research in the developing countries has multiple barriers including: lack of planning, lack of moral and financial incentives, and shortage of time available for research; underdeveloped health informatics structure; and lack of available funding.28 A multidisciplinary approach is vital to overcome these barriers. Basic scientists, health care providers, clinical researchers, educators, economists, and the private sector have to collaborate to overcome these barriers and perform high-standard vascular research to help our communities.

This study has some limitations. Quantity and quality of medical publications are considered as an indicator of research activity by many academic institutions. We have used only the MEDLINE journal database to locate the papers to be critically appraised. MEDLINE is a popular freely accessible database, which has defined standards for inclusion of journals. We did not critically appraise papers published in other databases. This is definitely a limitation of our study. Nevertheless, we think that the CIs of the percentages of different research areas in our sample are reasonable because of the accepted number of the studied papers. Furthermore, we have evaluated the quality using the impact factor of the Science Citation Index, although it has its own limitations.29 The real value of research comes from its positive impact on the health status of a community rather than from its impact factor.29 To conduct poor quality research is bad ethics, but to focus on the quality of research results or journal papers alone is insufficient. It is not very important to focus on trials of novel interventions in developing countries. Alternatively, applied studies to improve the implementation of proved interventions are of great value in developing countries. This includes emphasis on getting research findings into policy and practice.16

We have to highlight that we were focused in our research question and studied only articles related to vascular surgery, which is our main area of interest. Our present study does not cover all publications dealing with cardiovascular disease and it is only a step to define the road map to find solutions for this problem. We hope that this study will encourage other colleagues to study other areas of interest. Furthermore, defining lacking areas of vascular surgery research will not be useful unless it is matched with its actual community needs. This will be known after proper epidemiological and cost-effective studies have identified the burden of the disease in our community.

In conclusion, the quality and quantity of vascular surgery research in the GCC countries have to be improved to answer important local questions related to vascular diseases. It needs better strategic planning, and more collaboration between various institutions. A continuous data-collection system for vascular diseases will help in identifying priorities for prevention of vascular diseases and monitoring the effect of interventions. Areas of deficiency needing to be addressed are endovascular interventions, diabetic foot care, and cerebrovascular diseases. There is a desperate need to conduct community-screening projects, prevention programs, and patients education programs to cover vascular diseases in this part of the world. Obstacles to these endeavors can be overcome if we can convince our local communities that such initiatives are of overriding importance in terms of health and future economic prosperity.

## Appendix 1. List of excluded vascular surgery papers.

1. Andrade LA, Torresan RZ, Sales JF Jr, Vicentini R, De Souza GA. Intravenous leiomyomatosis of the uterus. A report of three cases. Pathol Oncol Res. 1998;4:44–47.

2. Elsharawy MA, Al-Quorain AA. Saphenoperitoneal shunt for intractable ascites. Saudi Med J. 2006;27:191–193.

3. Ibrahim MF, Refaat AA. eComment: acute type A aortic dissection at seven weeks of gestation in a Marfan patient. Interact Cardiovasc Thorac Surg. 2008;7:940.

4. Neglén P, Raju S. Detection of outflow obstruction in chronic venous insufficiency. J Vasc Surg. 1993;17:583–589.

5. Neglén P, Raju S. Compliance of the normal and post-thrombotic calf. J Cardiovasc Surg (Torino). 1995;36:225–231.

6. Steg PG, Bhatt DL, Wilson PW, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007;297:1197–1206.

7. Wali MA, Eid RA, Dewan M, Al-Homrany MA. Pre-existing histopathological changes in the cephalic vein of renal failure patients before arterio-venous fistula (AVF) construction. Ann Thorac Cardiovasc Surg. 2006;12:341–348.

8. Zukauskas G, Ulevicius H, Janusauskas E. An optimal inflow procedure for multi-segmental occlusive arterial disease: ilio-femoral versus aorto-bifemoral bypass. Cardiovasc Surg. 1998;6:250–255.

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